Substance Use Disorders (SUDs) and Medication Assisted Treatment (MAT) for Opiates

Transcription

1 Substance Use Disorders (SUDs) and Medication Assisted Treatment (MAT) for Opiates

2 What is MAT? Medication Assisted Treatment (MAT) is the use of medications, in addition to counseling, cognitive behavioral therapies, and recovery support services, to provide a comprehensive approach to the treatment of substance use disorders There are several medications currently approved by the FDA for alcohol and opioid dependence. Opioid dependence can be helped with the following medications: Zubsolv (buprenorphine/naloxone) Suboxone (buprenorphine/naloxone) Subutex (buprenorphine) Methadone (only available in an licensed outpatient opioid treatment program) Vivitrol (naltrexone) Alcohol dependence has three FDA approved medications Revia and Vivitrol (naltrexone) Campral (acamprosate) Antabuse (disulfiram) SUDS and MAT 2

3 Medication-Assisted Treatment (MAT) Reduces All-Cause Mortality Receiving treatment Untreated the all-cause mortality rate for patients receiving methadone maintenance treatment was similar to the mortality rate for the general population, whereas the mortality rate of untreated individuals using heroin was more than 15 times higher. Modesto-Lowe et al., 2010; Gibson, 2008; Mattick, 2003; Bell and Zador, 2000; Marsch,

4 MAT as Part of Treatment Program Four (4) approved medications for treatment of opiate dependency: Buprenorphine Methadone Naltrexone oral Naltrexone injectable MAT is an evidence-based treatment for opioid addiction; however, it is not a stand-alone treatment choice. MAT has proven to be very effective as part of a holistic, evidence-based treatment program that includes behavioral, cognitive and other recoveryoriented interventions, treatment agreements, urine toxicology screens and checking of PDMP. 4

5 Benefits of MAT MAT has been shown to stabilize physical cravings, as well as control behaviors that may lead to relapse Buprenorphine offers members a good chance of success because it is partial agonist, satisfies receptors to alleviate cravings, addresses withdrawal symptoms within 8 hours, allows engagement in recovery education and activities Substance use treatment, like the treatment for many chronic medical conditions, such as asthma or hypertension, requires a comprehensive range of treatment options Education regarding the full range of treatment options supports individual engagement in the recovery process of effective treatment options SUDS and MAT 5

6 WHAT? MAT = Meds + Recovery Services (PHP/IOP, Mutual Support Services) SUDS and MAT 6

7 MAT- can take multiple shapes MAT services are provided in a number of settings including an outpatient treatment program or provider s office Although medications help to alleviate the physical cravings for the drug, complete Recovery Services include individual, group counseling and social services. Recovery supports are services that include social support, linkage to service providers, and a variety of other services that facilitate recovery and contribute to an improved quality of life. MAT = Prescriber + Intensive Outpatient Programs (IOP) MAT = IOP, Partial Hospital Programs (PHP) (w/ prescriber) MAT=IP /Residential followed by prescriber + IOP A combination of three things together: therapy, recovery supports and medication provides the best chance for long term recovery. SUDS and MAT 7

8 Medications Buprenorphine (Suboxone )- appropriate for Opioid SUDs, medically stable, no psych comorbidity, indicate they are interested or prefer Suboxone. Physicians must meet certain requirements including a secure a registration number AND a unique identification number from the Drug Enforcement Agency (DEA). Naltrexone (Revia, Vivitrol- long acting injectable) FDA approved for treatment of Opioid and Alcohol SUDS, is not a controlled substance and can be prescribed by any healthcare provider licensed to prescribe medications with no special training. Some MDs do not have means to provide injectable. Methadone- Only offered in Federally licensed program (OTP), Often is excluded from coverage (check COCs), Appropriate for member s that have had multiple relapses, may have diverted meds and needs daily follow up for compliance SUDS and MAT 8

9 Buprenorphine expansion On Tuesday, November 15 th, the Department for Health and Human Services (HHS) announced additional steps to expand access to medication-assisted treatment (MAT) for opioid use disorders. Starting February 2017, Nurse Practitioners and Physician Assistants will be able to prescribe buprenorphine, a medication typically used to treat opioid use disorders. Once training requirements are met, Nurse Practitioners and Physician Assistants can apply for a waiver to treat up to 30 patients. Updates on training information and the waiver application will be available at SUDS and MAT 9

10 Our Focus : MAT and Opioid Dependence Members should be made aware / be offered treatment options for opioid dependence, including medication assisted treatment, especially buprenorphine (suboxone) for opioid dependence Members who have a history of opioid detox and relapse should be members identified for steering (education + influence, + offer options) to MAT services Trend- Opioid overdose deaths are rising, public health epidemic Drug overdose deaths by major drug types in U.S., pdmpexcellence.org SUDS and MAT 10

11 How is Buprenorphine MAT Delivered? Three (3) phases of Treatment for Opiate MAT with Buprenorphine based drugs: Treatment with these medication are typically used in three phases: Induction: Process of transferring a patient from opioids onto buprenorphine patient must be mild moderate state of withdrawal (Cows 10-12) before administering buprenorphine medications Can occur in an office or facility setting Involves evaluation of patient after initial dosing to assess and adjust dose to ensure withdrawal abatement Includes frequent medication checks (example: 2-3 visits in first week, followed by decreased visits as patient appears to stabilize) Stabilization Phase: involves finding the optimal dose for the individual patient Dose should eliminate all withdrawal symptoms, decrease cravings, eliminate other opioid use, and provide maximal functioning status Most patients stabilize on 8-24mg SUDS and MAT 11

12 How is MAT Delivered? Maintenance Phase- Reached when the patient is doing well on a steady dose of buprenorphine (or buprenorphine/naloxone) The length of time of the maintenance phase is individualized for each patient and may be indefinite Determinations regarding discontinuation of buprenorphine should be made based upon whether the patient has reached stabilization in key life areas (stable housing, income, relationships, etc.) Medically Supervised Withdrawal: The alternative to going into (or continuing) a maintenance phase, once stabilization has been achieved, is medically supervised withdrawal. This takes the place of what was formerly called detoxification. SUDS and MAT 12

13 Substance Use Disorders Specific Class: Buprenorphine-Assisted Treatment Establish Suitability for Treatment Discuss Substance Use History Assess Readiness for Change Confirm Support Systems/Networ ks Review Treatment Plan/Expectatio ns Day 1 Member in Moderate Withdrawals Initiate Induction Additional Meds Day 2 Re-Evaluate Discuss side effects, adjust dosage Prescription to last until next visit Review ongoing counseling and sober support use Continue to assess withdrawal symptoms Members begin stable daily dose Begin counseling, group therapy, and sober supports Relapse Prevention and Planning Weekly follow-up and drug screening Prescription only to last until next visit Continue stable daily dosage Decrease visit frequency Continue UDS with prescriptions Continue Counseling Involves Team decision Slow Taper With Counseling Sign Patient Contract SUDS and MAT 13

14 WHO is Appropriate for MAT? For Opioid use: determine and document if member is Buprenorphine MAT Candidate based on criteria: Adult 18 years old and over Primary Opiate Dependence Healthy Opiate Dependent - no serious, active co-morbid medical or psychiatric conditions, no active liver disease NO Exclusions SUDS and MAT 14

15 Are MAT Meds Covered? MAT Medication Pharmacy Benefit Coverage NHP provides coverage for medications to treat Substance Use Disorders such as Buprenorphine and Naltrexone via their Pharmacy partner CVS/Caremark Prior Authorization is NOT required for these medications Detailed information regarding medications covered can be found at NHP s website: SUDS and MAT 15

16 Access Standards for MAT Determining Access Standards for MAT If symptoms are mild to moderate (consistent with COWS 5-24) offer appointment within 24 hours If symptoms are moderately severe or severe (consistent with COWS > 25), needs appointment within 6 hours (non- life threatening emergency access standard) or send to ER Mobilization of family, social supports for treatment Stable recovery environment SUDS and MAT 16

17 Clinical Opiate Withdrawal Scale (COWS) Flow-sheet for measuring symptoms over a period of time SUDS and MAT 17

18 Current Evidenced Based Practice Lower levels of care with increased time in treatment Increases therapeutic alliance and compliance Increased time in treatment = decreased relapse Increased psychosocial intervention during withdrawal management = decreased relapse Treat within chronic disease model of care SUDS and MAT 18

19 Other Resources Link to Beacon Health Options PCP Toolkit, a resource to support PCPs in identifying and treating Behavioral Health Conditions: Link to SUD screening tools from SAHMSA: Substance Abuse Warmline: The Clinician Consultation Center offers free, real-time clinician-to-clinician telephone consultation, focusing on substance use evaluation and management for primary care clinicians. To speak with a clinician, please call , 10:00am 6:00pm, EST. Voice mail is available 24 hours a day. SUDS and MAT 19

20 Thank you SUDS and MAT 20